Wednesday, 24 September 2014

The government's newly created network of primary care clinics are struggling for recognition in China, according to a new survey carried out in Chengdu. More than 60% of people surveyed had not heard of the primary care clinics and didn't know where they were located, according to local media. Most people surveyed also said they would still prefer to go direct to hospital for treatment rather than go to a local community clinic, the survey showed.

China has seen huge reductions in hepatitis A over the last two decades, with rates of infection falling from 94% to 42%, a study carried out in Hebei has shown. Rising living standards, better hygiene and widespread childhood immunisation have contributed to the drop in hepatitis rates, and also resulted in most infections being delayed until adolescence rather than infancy, according to researchers from Shijiazhuang. However, the lower infection rates mean that many people now have little immunity to the disease and will benefit from immunisation, the researchers say.

A Tripadvisor-like mobile online platform has been developed that allows patients to rate their experience with hospitals and health providers in China. The Care Voice (Kangyu in Chinese) is a Shanghai-based social platform that enables consumers to share reviews on
hospital services, physicians and treatments and connect with other patients and
professionals.

Sunday, 21 September 2014

GSK's Mark Reilly, given a suspended prison sentence by Chinese court for bribery.

by Michael WoodheadThe main points of GSK's record 3 billion yuan ($500 million) fine for bribery in China have been reported elsewhere - I won't go over the same ground.

Suffice to say that several senior executives (including one from the UK) have been implicated in the giving of massive levels of bribes/kickbacks to institutions and hospitals in China to promote the use of GSK's drugs. The company was also found guilty of transfer pricing - dodgy accounting to transfer profits out of China via pricing mechanisms that favoured the revenues of the parent company over the China subsidiary.

Most of the western reports have focused on the implications for GSK and for the prospects of western businesses in China. Surprisingly few have questioned the ethics of what GSK was doing - except to suggest that "Chinese companies were all doing it, it's the way of doing business in China."
I have been reading some of the Chinese language media reports, and they give a lot more detail of the practices GSK was found guilty of. Very few western media reports have focused on the actual bribery methods used by GSK or the specifics of the transfer pricing arrangements (which I presume are not confined to China).

Here are a few examples reported in the Chinese media:

1. According to Chinese prosecutors the bribery was systematic and on a huge scale. Drug reps bribed doctors. Area managers bribed hospitals and 'VIP clients'. Country managers bribed officials in charge of distribution and purchasing. Bribery was done via travel agencies, gifts, sponsorship and through entertainment budgets and PR agencies. There were separate promotional teams for different product groups - the cold chain (vaccine) group is said to have spent 130 million yuan bribing officials in the regional Communicable Diseases Centres with everything from cameras and electronic equipment to cars.

2. How were individual doctors bribed? One liver specialist physician in Hunan called Dr Lee told the court how it worked. For every lamivudine prescription he wrote he was paid 20 yuan by GSK rep. For every new patient he got a bonus of 100 yuan. Dr Lee said every month he wrote about 150-200 prescriptions for lamivudine and started 5-8 new patients on the drug. Do the maths - that 12,000 yuan ($2000) a month, or 144,000 yuan ($23,400) a year. Dr Lee said the GSK rep arranged to pay him his commission every month at a special meeting when he would be paid for 'lecture fees' and travel expenses for the company. He received these fees 12 time a year but only did 3-4 lectures for GSK each year.

3. It wasn't just individual doctors who were bribed - the court heard how professional 'medical associations' also had huge sums of money transferred to their accounts from GSK to promote the endorsement and use of their products. Medical groups also received millions of yuan in material bribes such as non-medical items like fridges, cars and TVs. Hospital managers were also bribed millions to influence their purchasing policies - sales reps were given a 'Great Wall Plan' and a 'Dragon Plan' of incentives to persuade hospitals to abolish their 'Chinese-made generic drugs only' policies.

The end result was that Chinese consumers paid more for their medicines. Drugs such as Contac, Fenbid and lamivudine were overpriced up to
seven-fold compared to other countries. The unit cost of lamivudine was
said to be 142 yuan in China compared to 18 yuan in South Korea and 30
yuan in the EU, Japan and Hong Kong. Drug prices
were padded to pay for kickbacks. About a third of the cost of GSK
pharmaceuticals was said to have been to cover 'commissions', according
to a financial controller. This meant Chinese consumers paid 30% extra
for drugs just to cover the cost of bribes.

GSK was driven by high
pressure sales tactics for pharmaceuticals: GSK's revenue in China rose from 3.9 billion to 7
billion yuan between 2009 and 2012. The sales workforce increased from
1000 to 5500 people over that period, and each rep was given a budget
of 3000-5000 yuan per month to influence prescribing - presumably though
officials, doctors and health institutions. Sales reps were promised
unlimited bonuses and membership of an 'Elite Club' with foreign travel
if they met their targets

Cooking the books: from
2009-2013 GSK had almost 22 billion in revenue from drug sales in China
and yet recorded a profits of only 100 million yuan. Investigators found
this was due to a 'Five Step' transfer pricing system, by which the
costs of products such as the antibiotic Zinacef were inflated at
various stages of production in Italy and Cyprus until eventually 'sold'
to the China subsidiary. This was a way of repatriating profits back to
the US, but again meant that Chinese patients paid far more than they
needed to for drugs.

The overall picture is not pretty - call it what you want - commissions, kickbacks, bribes, - GSK was guilty of them but they were by no means the only pharma company in China doing it. Commissions and kickbacks are obviously widespread in the Chinese health system, and others have been caught out - such as in the Zhangzhou, Fujian case last year where 73 hospitals were found to be guilty of accepting bribes.

In Chinese media reports on the GSK case, most commentators have concluded that the massive fine and the jail sentences will be a lesson to the pharma industry - and the stamping out of bribes will result in lower medicine prices for Chinese consumers.

However, one leading financial commentator has said the GSK case is a prime example of China's tactic of "killing the rooster to scare the monkey" - but it would not work. Cai Shen Kun says corrupt practices are so entrenched in China's pharmaceutical industry and are so much a part of the healthcare system that even a major case like the GSK one will not put a stop to them. He says kickbacks have become an unwritten rule in the industry that all insiders believe that nobody can ignore if they want to make sales - even a major international company like GSK.

Cai Shen Kun says the long term solution is to reform the health and pharmaceutical system to make it transparent and remove the incentives for commissions. He also says nothing will change until those who accept the bribes are brought to justice - and that means prosecuting the government officials and senior doctors who accept the 'crazy money'.

Friday, 19 September 2014

by Michael WoodheadA survey of Chinese-trained nurses working in Australia has revealed some interesting insights into the role of nurses in the Chinese healthcare system.

Three main themes emerge from the interviews with 28 Chinese nurses working in Australia carried out by Zhou Yunxian from the Zhejiang Chinese Medical University, Hangzhou. In Australia, Chinese nurses found they had more independence and responsibility than they did under China's more regimented and hierarchical hospital system. Chinese nurses said they felt uneasy about having to take the initiative in patient care rather than be given orders by a senior nurse or doctor."Generally speaking, nurses here are more independent. They don’t rely on doctors totally. They can have their own thoughts and make decisions on the caring of patients," said one nurse.

Demarcation of roles is obviously stronger in the Chinese system - the nurses working in Australia found it strange that there was open communication and equality between nurses and doctors in a western healthcare system. "I don’t know what they (local colleagues) are doing, chatting with doctors – a waste of time from my perspective," said one, who believed that nurses should concentrate on 'nurses work' and not get involved with doctors.

Another theme that emerged was around the role of the nurse and their scope of practice. In China, nurses often saw themselves more as clerks and technicians fixing up IV lines rather than patient-oriented 'hands on' nurses. Chinese nurses were horrified to find that in Australian hospitals they were expected to do 'dirty' manual work such as bathing patients or helping to feed them. "I feel too embarrassed to tell people (the fact)…If I tell my family that a nurse in Australia needs to shower the patient, I think even my family would find it very hard to accept," said one.

This revealed that in China, manual work in hospitals is done by unqualified low-status 'care assistants', and personal help with feeding, toileting and bedding is the responsibility of the patient's family, not the nursing staff. Nurses from China also found it hard to adjust to the notion of a family leaving the care of a relative to 'the system' rather than taking personal responsibility - especially with the elderly and the way they are left in nursing homes.

A third theme that emerged was communication. In China, nurses expected to be given clear instructions about tasks from superiors, however they did not feel any obligation to communicate with patients or their families. Chinese nurses were surprised to find that in western hospitals, nurses were expected to be friendly and personal with patients, who they regarded as strangers. "Here every nurse calls everyone 'sweetie', 'love', things like that. It is totally different from us… I have never thought of addressing a patient so intimately. It is hard for us because we don’t feel this way," said one nurse.

Language and cultural differences also meant that Chinese nurses found their usual 'direct' style of communication appeared rude and imperious to westerners. They found it hard to be 'warm' and polite, believing this to be insincere. In contrast, Chinese nurses expected that their colleagues would become their workmates and were disappointed to find that westerners were out of the door at 5pm and not interested in networking. "Anyway, they (local colleagues) come when they are on duty and they leave when they finish the shift. In China, we are colleagues even after the work. We go out together, and then we become very good friends."

Although designed to investigate the problems of Chinese nurses adjusting to the western workplace, the study highlights many of the assumptions that underpin the Chinese health system

Wednesday, 17 September 2014

A female doctor in Shanghai draws weekly comic stripsand posts them on WeChat to try demystify medical jargon and improve doctor-patient relations
Dr Chen Haiyan, a cardiac ultrasonographer at the Shanghai Zhongshan Hospital has used the comic strips to explain conditions such as heart defects and high blood pressure in easy-to-understand ways. She also tries to explain the daily life of medical staff and show they are human in an effort to defuse the major tensions that have triggered many recent violent attacks against hospital staff.

Health experts have expressed disappointment that Beijing's proposed anti-smoking regulations have been watered down. The latest draft legislation only bans smoking in "shared indoor public places," compared to a previous draft that banned smoking in all indoor public areas, said Professor
Wang Qingbin, a legal expert at the China University of Political Science and Law,
"By banning smoking only in 'shared' indoor public areas, the legislators are giving officials with their own offices a chance to smoke, which is against the spirit of equality," Wang said, adding that it will only make law enforcement all the more difficult.

China lacks adequate health systems to deal with rare 'orphan' diseases such as Duchenne Muscular Dystrophy, medical experts say. At a recent conference on rare diseases at the Children's Hospital of Fudan University experts called for legislation and policies on the prevention and treatment of rare diseases that affect more than 10 million people in China."Related regulations should be created to help provide better support to patients with rare diseases and their families," said Li Dingguo, chairman of the rare disease branch of the Shanghai Medical Association.

Sunday, 14 September 2014

Internship scheme will create bottlenecks and headaches
Doctor training moves to a three-year internship system next year but many medics believe the changes will leave hospitals with even worse staffing shortages. The new system which will see newly-graduated doctors rotate through various hospital departments to gain experience is intended to bring China into line with other countries and to create a uniform high standard of medical practitioners. However, critics warn that the additional three years of being a trainee will mean that doctors earn very little and the low income will deter many from entering the medical profession. Another drawback of the new system is that doctors will serve as interns in tertiary 'teaching hospitals' and will then refuse to be 'downgraded' to work in smaller local country and township hospitals.

Ban on telehealth consultations triggers backlash
There has been a major backlash against an announcement that doctors will be banned from conducting online consultations by the National Health and Family Planning Commissioning. The NHFPC said this week that 'remote' consultations are illegal except through accredited medical institutions because all doctor consultations need to be carried out according to the regulations of the NHFPC as currently laid down for hospitals and clinics. The NHFPC said remote consultations should be viewed as no different to any other kind of consultation and therefore all the usual regulations on medical practice apply. However, after a major backlash from health groups and online health providers such as www.haodf.com, the NHFPC said it would look again at the legislation and would 'listen to the opinion of the masses' in interpreting the legislation.

Rural health insurance not working
People who live in remote rural areas of China are so poor they cannot afford to seek medical attention when they are sick, a study from Hebei has found. More than 50% of people living in the Dabie mountain areas of Hebei said they would not seek medical care if they felt unwell. The main reason (for 38% of people) was financial difficulty. Other reasons included inconvenience and preference to self medicate. Researcher Dr Fang Pengqian and colleagues from the Tongji Medical College, Wuhan said the findings suggested that the universal health coverage from the New Cooperative Medical Scheme (NCMS) was was not working for people in poorer highland areas. They said the locals could not afford to pay the necessary insurance premiums to cover basic care and the low reimbursement meant they faced high out-of-pocket costs.

Friday, 12 September 2014

by Michael WoodheadThe Chinese government appears to have side-stepped the influential doctors' lobby and the tame health ministry by using the Ministry of Commerce to tackle the perennial problem of drug sales commissions and the inflated cost of medicines.

Doctors in China rely for much of their income on commissions and bonuses from sales of pharmaceuticals, and previous efforts to curtail the profits have been stymied by medical lobby groups. The Ministry of Health, previously led by a medic Dr Chen Zhu (who now heads the Chinese Medical Association), has managed to block or delay previous efforts to tackle the drug commissions problem.

Now the government has turned to the Ministry of Commerce to introduce new rules that separate medical services and drug sales in 34 pilot cities across the country, in an attempt to lower the high cost of medicines.
The National Health and Family Planning
Commission (which absorbed the Ministry of Health last year) has been sidelined by the move, a sign that its own efforts at reform have failed.

Under the new Ministry of Commerce plan, major city pharmacies will replace hospital pharmacies as the source of prescription drug dispensing, putting an end to the lucrative 'gold mine' of revenue for hospitals. In theory, this will mean that hospitals should no longer pressure their doctors to prescribe more and reach quotas to boost revenue via the hospital pharmacies. And by breaking the hospital pharmacy monopoly, the new plan will lower drug prices by encouraging competition between pharmacies.

According to Caixin, previous efforts to break the drug sales-hospital income link have failed because of entrenched opposition from the
former Ministry of Health.
The ministry pushed a plan under which local governments purchased pharmaceuticals on behalf of local hospitals, but this scheme was ineffective in breaking the stranglehold of hospitals on drug demand and also proved to be yet another channel for corruption.

The new scheme will also permit more pharmacies to become eligible for reimbursement under the various medical insurance system. These moves will further increase diversity and competition and give pharmacies a boost in business, commentators say. However there has been no analysis of how public hospitals will make up for the huge gap in revenue when their lucrative pharmaceutical monopoly is snatched from them.

Wednesday, 10 September 2014

Robotic surgery is now being used by hospitals in China, with the da Vinci surgery robot system completing its first operation at the
Provincial People's Hospital in Chengdu. The 30 million yuan ($5 million) system can perform accurate and less invasive
surgery in cases such as prostate cancer and gallbladder procedures but has been criticised by some clinicians as being an expensive
system with a steep learning curve that does not offer any real
improvements in outcomes compared to conventional surgery.

A Chinese man with cancer who became famous for using Weibo to solicit donations for his medical bills has died. Noodle shop owner Li Gang of Zhengzhou raised $16,000 to pay for medical treatment which he could not afford in 2012. His message went viral and he had many visitors to his noodle shop, but some commentators said it highlighted the lack of affordable medical care for most Chinese people with cancer.

Tuesday, 9 September 2014

by Michael WoodheadIn China there are about 8 million unnatural deaths every years and of these about 400,000 are said to be due to medical accidents - often due to unsafe use of medicines. To try and remedy this poor situation, September has been nominated as national medication safety month by the China State Food and Drug Administration.

The survey found that there were many problems with the way Chinese people used medications. About 90% bought prescription drugs from pharmacies and self-treated without getting advice or a diagnosis from a doctor. Almost 70% did not read the package insert and a third made major mistakes in dosing while 25% did not take the medicine correctly and failed o get the expected benefit.

Zhang Jichun said many of the problems with drugs occurred in children and the elderly, who were more susceptible to their effects. A typical and common avoidable serious problem was deafness seen in 300,000 children due to overuse of some classes of antibiotics. This side effect occurred due to parental medication without being aware of the risks.

In the elderly one of the main problems was excessive medication, he added. Many elderly people take several different drugs for various ailments without understanding that they can interact to cause severe side effects, he said. Elderly people also made the mistake of taking western medicines with Chinese traditional medications, and this could also cause problems he said.

To try address this problem the China Pharmaceutical Association has set up a "medication safety expert advice hotline” and invites all Chinese to seek advice before using medications.

Sunday, 7 September 2014

After featuring many articles from the Lancet's China-themed issue it is only right that I give some attention to an article published by their competitor, the BMJ.

This week a blog post from four Chinese doctors lamenting the long hours they have to work. According to the lead author, Dr Luo Deng (an endocrinologist at the Shanghai Jiao Tong University Affiliated Sixth
People’s Hospital) China's doctors work an average of 11 hours a day, six days a week. That's an average - not the maximum. And before you jump in and say that many doctors in other countries work those long hours - remember that Chinese doctors earn about $5000 a year.

The working hours figure comes from a survey of more than 3771 Chinese doctors, which found that 80.5% worked more than eight hours in hospital every day. The exact figures were an average of
11.22 hours per day for 5.62 days a week, with only one day off.

"On top of this, we fear that the increasing number of daily hospital
outpatient visits, along with administrative or academic affairs, may
further contribute to the imbalance between family and career in
doctors’ lives," the doctors write.

The doctors blame the heavy workload on a huge increase in patient consultations in the last decade - up from from 1.21 billion in 2001 to 2.74 billion in 2013.
During that time, hospital admissions increased nearly fourfold, but the Chinese government still spends only about 5% of its GDP on health, compared to 8.8% for Brazil and 9.2% for South Africa.

"With a generally high patient to physician ratio in most practices, and
near constant patient contact throughout the workday, most physicians
find it difficult to take even a short break. Even the public of China
has begun to raise concerns about the physical and mental health of
physicians; however, these issues probably remain unknown to much of the
world," the Chinese doctors write.

They suggest, quite meekly, that the government implement "effective and efficient measures ... to improve the
health of China’s medical staff, and boost their career enthusiasm amid
the stressful job atmosphere."

Smoking cessation efforts are doomed to fail in rural China unless the culture of giving cigarettes as gifts can be broken, say researchers from the Ministry of Health in Jinan, Shandong. Their study found that although many people in rural China attempted to quit at the advice of other family members,
relapses were common and few were able to quit completely because they were culturally expected to share cigarettes. The study also found that village doctors did not smoking cessation advice
to all patients and there were few if any smoking cessation programs in rural areas.

Allowing foreign companies to set up and operate hospitals in China will not make much difference to overstretched health services, a leading health official says in Caxin. Lian Xinbo says the real barriers are in employment and insurance regulations which mean that foreign companies will find it difficult to attract talented doctors and also to offer services that are reimbursed by health insurers.

More than 500 Chinese children die of rabies every year, and tragically most of the deaths could have been avoided if children had received correct treatment, say clinicians from the National Institute for Viral Disease Control and Prevention in Beijing. Most of the rabies cases occur in rural areas and are due to bites by domestic or stray dogs. However, few children with rabies get the recommended treatment of post-exposure rabies injections or even adequate wound care.

Thursday, 4 September 2014

Some insider views of the Chinese medical education system have been published as part of The Lancet special China-themed issue this week. The rather gloomy conclusion is that China's vast medical education system is failing to attract good students and failing to produce graduates who are able and willing to work as doctors.

A review article notes that China made some major reforms to medical education in 1998, greatly expanding the number of students to produce half a million would-be doctors a year. However, many of these medical graduates do not enter medicine but take up other careers. Why is this? The review authors say there "is a mismatch of health professional education and employment opportunities".

Another article in the same issue of the Lancet throws further light on the lack of enthusiasm for medicine as a career: Dr Yang Pengfei of the Changhai Hospital, Second Military Medical University, Shanghai, says most doctors now advise their children against taking up a career in medicine and only 7% would recommend it. He cites the breakdown in trust and respect between patients and doctors and the tide of violence against medical staff - 30 killings in recent years by disgruntled patients and their families. Dr Yang notes that even the best medical schools such as Peking Union Medical College are now struggling to attract high quality students.

"The national admission score for a graduate student majoring
in medicine has also declined for three consecutive years, according to the
Chinese Ministry of Education. It is no longer the best students who go to medical school. This is a growing concern: who will be tomorrow's doctors?" he asks.

The review article says the problem of poor relations between patients and doctors is due in part to the narrow and inflexible education system that fails to instil students with the values, ethos, and ethics of the medical profession and also fails to produce doctors with good communication skills and characteristics such as empathy.

"The curriculum system still focuses narrowly on
biomedicine, medical technology, and clinical practice. Pedagogic
methods are rigid: mostly teacher-controlled didactic lecturing, which
requires rote memorisation by students. The increase of disputes between
doctors and patients, and violence against doctors in China might be
associated with these deficiencies in education," it says.

Another problem with medical education in China is that it is still rigidly hospital focused and geared towards producing narrow specialists rather than generalists who can work in the community or in rural health.

"Therefore, it is not surprising that the graduates have limited
knowledge about primary care services and prevention of diseases."

Will things improve in the near future? It's hard to see how, as huge class sizes are a barrier to more innovative teaching methods such as problem-based learning, and encouraging
interaction and discussion.

China's medical schools may need to take a leaf from the book of China's factories. Instead of mass producing unpopular low quality products they could adapt the best foreign know-how and methods through joint ventures to produce a wider range of higher quality sought-after products.

Tuesday, 2 September 2014

Eradication of schistosomiasis in China is being hindered by factors such as lack of political and financial support, praziquantel resistance and climate change, say clinicians from the Jiangsu Institute of Parasitical Diseases in Wuxi. A sense of complacency has set in since the prevalence of schistosomiasis was reduced to about 1% in animals and humans, they say. Renewed efforts are needed to ensure the final elimination of the parasite by 2020 and avoid its re-emergence, they say.

Young Chinese are signing up to be human guinea pigs in pharmaceutical drug testsand
trials, being paid up to 10,000 yuan to be injected with experimental
drugs. Medical students are the most popular choice for the first human
trials of the 10,000 different trials run by China's 6,000
pharmaceutical firm.

China's leading medical social network site DXY has received $70 million
in investment funding from Tencent, which will start to use the doctor
networks as part of its services to consumers in the form of online
consultations and appointment booking services. DXY will also develop
new products in the healthcare area for consumers as well as doctors.

As Drs Yang and Hao remark, there has been a tidal wave of medical journal articles published by Chinese clinicians in recent years, and yet medical publishing is in crisis. Why? Because most of it is crap. Scholarly articles are not being published to to be read or to further scientific knowledge, but to be listed and to obtain the magic piece of paper that counts towards career advancement.

Well, you might say, this sort of things happens to all academics and clinicians and you'd be right. But the scale of the problem in China - and the sheer numbers involved - means this is distorting medical publishing and also drowning out the genuine research and academic discussion that deserves to be published but which struggles to reach the most suitable audience.

Another problem noted by the doctors from the Medical College of Xi'an Jiaotong University is that most doctors in China don't read English language journals. They may only have access to Chinese language journals and these are poor in quality because they being neglected by Chinese researchers - and they are also often profit seeking rather than having any sense of collegiality. As the authors note, Chinese doctors deal with 4 billion patient consults a year and they depend on Chinese medical journals as their main source of medical information - if this is rubbish, where can they get good quality research, evidence and discussion from to inform their practice?

"Rebuilding a scientific and reasonable assessment system for medical
research would be an essential step for the Chinese government," the authors conclude.

This isn't the first complaint about medical publishing in China. The Economist touched on the problem of poor quality - and sometimes fake - medical research publications last year. Other bloggers have also highlighted the bizarre practice of bonuses paid to researchers in China in proportion to the impact factor of journals they get published in: $300 for a low impact journal, and the jackpot of $30,000 for getting a paper in Science or Nature! This reminds me of Chiang Kai Shek's system or rewarding his air force pilots with dollar bonuses for every enemy aeroplane they shot down.